Utah Admin. Code R539-1-8 - Medicaid Waiver Eligibility and Enrollment for the Limited Supports Waiver
Current through Bulletin 2022-07, April 1, 2022
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(1) The Division will serve those Applicants who meet the eligibility requirements for brain injury services. To be determined eligible for non-waiver brain injury services the Applicant must:
(a) have a documented qualifying acquired neurological brain injury from a licensed physician (MD or DO).
(b) Be 18 years of age or older;
(c) score between (36 and 136) on the Comprehensive Brain Injury Assessment Form 4-1.
(d) meet at least three of the functional limitations listed under number (4).
(2) Applicants with functional limitations due solely to mental illness, substance use disorder or deteriorating diseases like Multiple Sclerosis, Muscular Dystrophy, Huntington's Chorea, Ataxia or Cancer are ineligible for non-waiver services.
(3) Applicants with intellectual disability or related conditions are ineligible for these non-waiver services.
(4) In addition to the definitions in Section 62A-5-101(2) and (8), eligibility for brain injury services will be evaluated according to the Applicant's functional limitations as described in the following definitions:
(a) Memory or Cognition means the Applicant's brain injury resulted in substantial problems with recall of information, concentration, attention, planning, sequencing, executive level skills, or orientation to time and place.
(b) Activities of Daily Life means the Applicant's brain injury resulted in substantial dependence on others to move, eat, bathe, toilet, shop, prepare meals, or pay bills.
(c) Judgment and Self-protection means the Applicant's brain injury resulted in substantial limitation of the ability to:
(i) provide personal protection;
(ii) provide necessities such as food, shelter, clothing, or mental or other health care;
(iii) obtain services necessary for health, safety, or welfare;
(iv) comprehend the nature and consequences of remaining in a situation of abuse, neglect, or exploitation.
(d) Control of Emotion means the Applicant's brain injury resulted in substantial limitation of the ability to regulate mood, anxiety, impulsivity, agitation, or socially appropriate conduct.
(e) Communication means the Applicant's brain injury resulted in substantial limitation in language fluency, reading, writing, comprehension, or auditory processing.
(f) Physical Health means the Applicant's brain injury resulted in substantial limitation of the normal processes and workings of the human body.
(g) Employment means the Applicant's brain injury resulted in substantial limitation in obtaining and maintaining a gainful occupation without ongoing supports.
(5) The Applicant shall be provided with information concerning service options available through the Division and a copy of the Division's Guide to Services.
(6) The Applicant or the Applicant's Guardian must be physically present in Utah and provide evidence of residency prior to the determination of eligibility.
(7) It is the Applicant's or Applicant's Representative's responsibility to provide the intake worker with documentation of brain injury, signed by a licensed physician;
(8) The intake worker will complete or compile the following documents as needed to make an eligibility determination:
(a) Comprehensive Brain Injury Assessment Form 4-1, Sections A through L; and
(b) Brain Injury Social History Summary Form 824L, completed or updated within one year of eligibility determination;
(9) If eligibility documentation is not completed within 90 calendar days of initial contact, a written notification letter shall be sent to the Applicant or the Applicant's Representative indicating that the intake case will be placed in inactive status.
(a) The Applicant or Applicant's Representative may activate the application at any time thereafter by providing the remaining required information.
(b) The Applicant or Applicant's Representative shall be required to update information.
(10) When all necessary eligibility documentation is received from the Applicant or Applicant's Representative, Division staff shall determine the Applicant eligible or ineligible for funding for brain injury supports.
(11) A Notice of Agency Action, Form 522-I, and a Hearing Request, Form 490S, shall be mailed to each Applicant or Applicant's Representative upon completion of the determination of eligibility or ineligibility for funding. The Notice of Agency Action, Form 522, shall inform the Applicant or Applicant's Representative of eligibility determination and placement on the waiting list. The Applicant or Applicant's Representative may challenge the Notice of Agency Action by filing a written request for an administrative hearing before the Department of Human Services, Office of Administrative Hearings.
(12) Persons receiving Brain Injury services will have their eligibility re-determined on an annual basis. Persons who are determined to no longer be eligible for services will have a transition plan developed to discontinue services and ensure that health and safety needs are met.